Apr 01, 2013

The Evolution of Primary Care in Alberta

Over the last decade, Alberta has been making strides in reforming its primary care system. Family care clinics, a new model for the province, were introduced by the ruling Progressive Conservatives during last year’s election campaign. The budget released in March earmarked $60 million for the creation of more FCCs, signalling the government’s commitment to the model. A few days before the budget, Canadian Nurse spoke with Alberta Health Minister Fred Horne to find out about the government’s plans for primary care renewal.

CN: One of the priorities for Alberta Premier Alison Redford has been better access to primary care for all Albertans. Why is this so important?

FH: It has been my observation in talking to Albertans and health-care providers that people are really looking for more support at what I call the “front door” of the health-care system. People will tell us that when they went to the hospital for surgery or cancer treatment, for example, the quality of care was fantastic, but, and they actually use these words, the only problem was getting in the door. I think it is quite a telling comment, and a sign that we need to focus more on primary health care and providing as many services as we can in the community, as opposed to doing things in the hospital that we don’t need to do there. We know we can do more with the resources we have.

CN: Currently, Alberta has two team-based approaches to primary care: primary care networks, which are physician-led, and the new family care clinics. How are you moving forward with them?

FH: We established primary care networks (PCNs) back in 2003. PCNs are networks of local physician offices; there are 40 of them in Alberta. The family care clinic (FCC) is designed to enhance primary health care delivery across the province. We have three of them in operation now, in Edmonton, Calgary and Slave Lake.

The FCC is really a stand-alone clinic. One of its features is the ability to respond to unique community needs. For example, in Slave Lake, there was a very serious fire a little over a year ago, and five physicians left the community. The FCC has been important in restoring a more adequate level of primary health care services to that community through the use of not just the remaining physicians, but obviously the other providers who are working with them as part of the team.

In Edmonton, the FCC is in an area of the city where there is a large number of unattached patients. For many people, their only option for care was the emergency department at the Royal Alexandra Hospital, where they were being seen on an episodic basis. There is a large number in that part of the city who have a need for addiction and mental health services, and there is a large number of new Canadians, new Albertans, whose first language is not English. The FCC in east Edmonton was uniquely designed to meet those needs, among others.

But we actually see the role of both the PCN and FCC as broader than just delivering health-care services. For example, we have an early childhood development strategy in Alberta now that is run by the Ministry of Human Services. The minister and I are working together on options to deliver some of those services through the primary care platform. That opens up opportunities for a more integrated approach, in which you are able to address the social determinants of health in addition to access to health care.

Equally, we see the FCCs and PCNs as a way to deliver a better care experience when people need more specialized services in the system. In both models, we are working on options for specialist linkages for the people who have their home in the health system at an FCC or PCN. Their access to specialist services would be coordinated from the primary care level; that would include everything from booking the appointment with a specialist, to the arrangement of lab and diagnostic tests that might be required, right through to assistance with navigation in the system at the tertiary level.

They are models for delivery, but they are also designed to capitalize on the relationship between patients, families, communities and the local health-care team. The notion of attachment is really important and is key to their success.

CN: How are the social determinants of health addressed by offering early childhood development programs through clinics?

FH: We are in the early stages of planning this, but the idea is that we have services and expertise that we want to deliver to Alberta children and their families. These services support the success of children in the school environment and they also support their parents, particularly parents who might face challenges because of a lower socio-economic status or because of addictions or mental health issues. The idea is to look at using the primary care platform as a vehicle to deliver those kinds of services. It’s not just service delivery; it’s the fact that the staff are able to work together, can share information and do case planning on a coordinated basis. If a child happens to have an ear infection, we are not only treating that but we are also using the opportunity of the interaction with that child and family to try to support them in other areas of their development. Also, in that same vein, we are building new schools in Alberta and we are looking at opportunities to locate some of the FCCs in them; because that, of course, is the best place to reach children — in the school system.

Two models of teamwork

Primary Care Networks (PCNs) are joint venture agreements between a group of family physicians and Alberta Health Services funded by Alberta Health to provide comprehensive primary care to a population. PCNs are a physician-led model and largely rely on fee-for-service physician compensation. PCNs are a network of physician offices and clinics covering a geographical area. Over the past eight years, PCNs have become the main model of primary care delivery in Alberta. There are currently 40 PCNs operating in the province, involving over 2,900 family physicians and more than 700 full-time equivalent other health-care providers who deliver primary health care services to over 2.9 million Albertans.

Family Care Clinics (FCCs) are local, team-based primary health care delivery organizations that provide individual and family-focused primary health care services aligned with the needs of their community. These clinics coordinate the provision of a comprehensive range of primary health care services that cover an individual’s lifespan from birth to death. In April 2012, three pilot Family Care Clinics began operations, in Edmonton, Calgary and Slave Lake. FCCs provide Albertans with direct access to the most appropriate member of a health-care team who can address their health and social needs. Team members may include nurse practitioners, registered nurses, family physicians, dietitians, pharmacists, mental health professionals and others.

CN: How will you decide where the next FCCs will go?

FH: We’ve done a health needs assessment for all communities in Alberta and have data that give us a better picture of the health status, the access to resources, the health workforce that is available and some of the agencies that exist in each community. We will be sharing the data with the communities and supporting them with staff, from my ministry, to develop proposals based on their unique needs.

A lot of times in health care we see kind of a “cookie-cutter” approach, for lack of a better term. This will be more of a community-driven option for primary health care delivery. It will probably take a bit longer because if you are going to engage people you have to support them with information and resources to put together proposals — that’s not an easy thing to do. It is a bit of a challenge in the sense that people are used to kind of a top-down approach where government says: this is the program, these are the resources, they have to be used in this fashion and it is the same for everyone. This is a little different. I have always been a believer that one of the most important purposes of having a publicly funded universal health system is to improve the health status of our own people over time; as you are probably aware, this is the first generation of Canadian children to have a lower life expectancy than the generation that precedes them. This is a very serious issue. Obviously, we have to ensure that people have access to the services they need when they are sick, but there is a real wellness side to this approach that is focused on better health.

CN: What is the goal behind the commitment to FCCs?

FH: To give every Albertan a home within the health system — the home being an identifiable team that they belong to. Doctors will be important, but nurse practitioners, registered nurses, pharmacists and others are also going to play an important role. When you think about things like chronic disease, for example, we see multiple morbidities frequently now. Even though our population is younger than is the case in other provinces, we are seeing this on a regular basis, so there is complexity that is involved. Sometimes, the other providers are better suited to meet a patient’s individual needs.

CN: What role do registered nurses play in the creation of FCCs?

FH: Nurses in Alberta are providing a tremendous amount of leadership. They’re leading the important discussions about how we shift to true interdisciplinary care. Their leadership is meeting with a lot of positive feedback from other professions…that’s been really important. Sometimes we hear people debate about where clinical leadership should come from in primary health care and my answer to that is: I don’t think it is something that can be prescribed. Certainly, it is not up to politicians to prescribe that. In most cases, we see the effective team is the team that responds to the needs of the patient, family or community as they are presented. That is what our providers in Alberta have been doing, and I have to give them credit for it.

Also, nursing leadership is part of the group working on the primary health care strategy for the province (the Minister’s Advisory Committee on Primary Health Care). The group is representative of both consumers and providers of care and people from other ministries in the social policy area. The high-level framework they create will guide the development of standards and look at questions like funding and accountability. They are talking about things like what core services should be available to every Albertan through primary health care and what enablers are needed to improve the care experience, and how we can get to a one patient, one record system. They are looking at how individual communities can better link with agencies that support health — these would be areas that support employment, income supports that are available, and services for seniors that are provided through volunteer agencies.

CN: How will the PCNs be changing as part of this renewal?

FH: We have a group that we call the PCN 2.0 that is led by the Primary Care Alliance of Alberta, which represents people who have been involved in PCNs over the last eight or nine years — doctors, nurses and other professionals. They are developing a vision for the next generation of PCNs. For example, there has been some excellent work in chronic disease management, but although we have seen pockets of innovation in different areas across the province, we haven’t really leveraged those things for the benefit of the whole province. The idea is to move to a more standardized approach to enhance the role of evidence and achieve the highest possible level of integration amongst providers and with other parts of the system.

At the same time, we need to leave room for communities to innovate according to their needs.

A PCN in the north part of Edmonton has worked with orthopaedic surgeons to develop a screening process right in the primary care clinic. They have trained staff to do things like recognize a hairline fracture or distinguish a back pain issue from something that is maybe hip- or knee-related. The result is that the PCN has been able to divert more than 75 per cent of the people who were in the queue to see an orthopaedic surgeon. They have been able to identify that those people actually don’t need to see a surgeon and are providing them with other resources to address their particular issues. Imagine if we replicated this, not only in orthopaedics, but in areas like colorectal cancer screening, and further customized it by cohort within the panel of patients. It is a very powerful tool to not only free up scarce resources like time with an orthopaedic surgeon, but also to catch people who are at risk for a chronic disease and enable them to pull themselves back from the threshold. Diabetes is probably the best example of this: we have collected the A1C levels in blood tests in Alberta for years and years, but our system has never been organized in such a way that we could reach out to the people who are just on the borderline. I think most people, if they had that information, would be quite motivated to do what it takes to pull themselves back — through diet, exercise or whatever the other factors may be. To me, that is the real power of primary health care renewal. The FCCs are interesting because they are a new model, but it’s not really about the model. It’s about capitalizing on all of the opportunities available to us in primary health care and to stop doing things in the hospital that we know we can do in the community.

CARNA CEO reacts to the budget

Mary-Anne Robinson, CEO of the College and Association of Registered Nurses of Alberta:

The Government of Alberta confirmed its commitment to strengthening primary health care with a 20 per cent increase in funding for primary health care and addictions and mental health. This funding is an important part of the province’s ongoing, long-term commitment to make primary care available to more Albertans. Primary health care, with its focus on patients, listening to their needs and concerns, and helping them access the health-care provider who is right for them, supports the core tenets of our profession. It also opens the door to new opportunities for RNs and NPs to engage more fully with families and communities. As a member of the Primary Health Care Strategy Working Group, I have been privileged to work with other providers and community leaders invited to join government in creating a primary care system where every individual has access to the care they need and where there will be greater understanding and synergy between health-care providers.

CN: A major theme in the 2012 report from the Council of the Federation’s health-care innovation working group is the need to share best practices across the country. How will Alberta do this?

FH: The health-care providers in Alberta already share a lot just through their regular interaction with their peers across the country. When you collect data about outcomes, and when you use evidence to support what you are doing and are transparent about the results that are achieved, providers are quite interested and quite willing to compare their outcomes with their peers’ outcomes, have a discussion about unexplained variances and refine the process to make it better. I think there is a tremendous amount of power in that, and we have not fully realized it yet. Part of it is the government coming forward and providing leadership, but part of it is enabling health professionals and equipping them with data and allowing them to exercise clinical leadership within their own disciplines. For all of the things I have talked about, data is going to become increasingly important because this is the only way we are going to be able to measure what we are doing.

CN: Does the fact that Alberta has one central health authority make it easier to collect and disseminate data?

FH: Yes, it makes a huge difference. We are still in the process of consolidating many of the information systems from the former regional health authorities — that is a big job. But we have a vision for a fully integrated electronic medical record for the province. The traditional functions of an electronic health record, like we have, provide access to imaging, lab test results and those sorts of things. If we could achieve one record for one patient and we had the appropriate protocols in place, so professionals could share that information, obviously with the consent of the patient, you can imagine the possibilities. Then, when you have a common platform, like Alberta Health Services, all of your citizens can share in the benefits. It is much easier from a change-management point of view when you are working with a single system. I really see Alberta Health Services as an enabler of the primary health care renewal work that we are doing.

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